case 5 - Case 5: Acute NSLBP with somatic referral (L4/5?)

Question 1

assessment priorities

Answer 1

Functional tasks (within limits of pain)
AROM
palpation/paivm

Question 2

assessment priorities
Functional tasks (within limits of pain)

Answer 2

a. Sit to stand
i. Replicate some symptoms
ii. Functionally relevant
iii. Look for apprehension, maladaptive behaviours
b. Standing
. Observe for lat shift
i. Can do TDT for repeated ext (more likely to be this) then have baseline with VAS
c. Sitting bc needs to do this for job
If i can correct poor sitting posture then is leading to treatment

Question 3

assessment priorities

AROM

Answer 3

• Baseline measure & reassessment (shows patient they getting better)
• See side to side differences
• So that we can communicate with other health professionals (even insurers etc) and to help with documentation about the patient
• Observe pain, apprehension/fear, maladaptive behaviours
  Directional preference stuff here

Question 4

assessment priorities

palpation/paivm

Answer 4

(do in side lye if can’t tolerate prone bc very irritable)
a. Very irritable, check for sensitivities
b. Patient satisfaction
c. Find segment/ referral
Can see if improve ROM after isolations?

Question 5

management priorities

Answer 5

1.Advice and education
2. Exercises to directional preference
. Manual therapy

Question 6

management priorities

1.Advice and education

Answer 6

• diagnosis: , I have found that you have not sustained any major injuries to your back and are experiencing some symptoms around the L5/S1 region of your back (show on model):
  • You didn’t have any major trauma and you aren’t experiencing any symptoms down your legs.
• Good prognosis → improve in 1-2 weeks, 80% recover in 4-6
• Reassurance: The spine is strong, resilient and adaptable.
  Pain is poorly related to tissue damage especially because you didn’t experience any traumatic injuries to your back however nervous system is very sensitive.
• Activity modification: short 10 min walks with dog more frequently than long walks, get back to work ASAP = Discuss potential temporary work modifications – minimize prolonged amount of time in any positions.

Work = chair support temporarily (cushion, towel and also in car), re-educate sit to stand correctly, decreases length sitting so short standing breaks, increase breaks

• Pain management: Some initial rest until your symptoms settle down slightly and then we want to get you moving as soon as possible. Repeated movements into extension have been found to relieve your symptoms, so we can use that as part of your management.
• Modification of sitting posture → lumbar roll or cushion
  Regular breaks

Question 7

management priorities

2. Exercises to directional preference

Answer 7

• Repeated extension in standing

- gentle repeated extension in standing if tolerated and prone repeated extension onto hands if he can get into prone.

Question 8

management priorities

. Manual therapy

Answer 8

• Segmental rotation or reverse lateral flexion
• if successful, consider increasing the grade of the rotation mobilisation. Consider MWM to extension in prone. Maybe paiv if prone tolerated
  Massage → L) QL + ES

Question 9

other management

Answer 9

. Gentle exercises
- 4pt kneel kneel → Cat-cow
- Sitting - pelvic tilts
Progress to short walks